Q&A: Allergists answer common caregiver questions about food allergy
Click Here to Manage Email Alerts
Key takeaways:
- Caregivers should introduce peanut into diets at age 4 to 6 months.
- Allergist visits are not needed before introducing allergens.
- If reactions happen, caregivers should seek immediate help.
Caregivers of infants at risk for food allergy have many questions for their pediatricians. Allergists routinely hear these questions too, and they have time-tested answers for these caregivers based on years of experience.
Healio asked John M. James, MD; Abigail Lang, MD, MSCI; and Scott H. Sicherer, MD, FAAP, to share the most common questions they hear as allergists and what they tell the families they treat.
James is a medical consultant in food allergy and other allergenic diseases as well as president of Food Allergy Consulting and Education Services.
Lang is an assistant professor of pediatrics at Northwestern University Feinberg School of Medicine and an attending physician in the division of allergy and immunology at Robert H. Lurie Children’s Hospital of Chicago.
Sicherer is a professor of pediatrics and director of the Jaffe Food Allergy Institute at the Icahn School of Medicine at Mount Sinai.
Healio: Why is it important to introduce allergens early?
Sicherer: Recommendations about timing of introduction of allergens to reduce the risk for allergy have changed dramatically over the past 20 years, from early suggestions to avoid them for years in babies prone to allergy to today’s view that a diverse diet that includes early introduction of allergens may be protective.
The theory, proven most specifically for peanut, is that early ingestion allows the immune system to “learn” correctly that peanut is an innocent food protein. When the food is not eaten, there is a potential that the body is exposed to it anyway, particularly on the skin, because food is a ubiquitous item in our environment. Especially for infants with eczema where the skin barrier is poor and allergic inflammation is occurring, this nonoral exposure may hype up allergy, whereas oral ingestion protects against that.
James: Over the past decade, several clinical research studies have demonstrated that the early introduction of certain food allergens, especially peanut and egg, can help to prevent the development of these food allergies in susceptible infants. There does appear to be the existence of a critical time early in infancy during which genetically predisposed and atopic infants are at a higher risk for developing allergic sensitization to food allergens. These dietary interventions at specific times during early infancy, such as the early introduction of food allergens, have been critical to the development of oral tolerance to these foods and the prevention of food allergy.
Healio: When should I introduce peanut and how?
Sicherer: There is more than one recommendation active in the U.S. and globally currently but, in general, the advice is to introduce around age 6 months but not before age 4 months. For babies with eczema, earlier in the 4- to 6-month window may be better. Once introduced, keeping it as a regular part of the diet is advised.
Talk to your pediatrician about the introduction of solids in general. Some foods, such as peanuts and peanut butter, can be choking hazards for babies, and infant-safe forms have to be used. This can be as simple as smoothing out peanut butter into a pureed fruit or vegetable or to use water. The National Institute of Allergy and Infectious Diseases has provided a handout.
James: The timing of peanut introduction in early infancy varies based on the risk for the infant developing peanut allergy. In infants with severe atopic dermatitis or egg allergy or both, peanuts should be introduced at age 4 to 6 months. In infants with mild to moderate atopic dermatitis, this introduction should take place around 6 months of age. Finally, infants with no history of allergies can be introduced to peanuts based on family and cultural feeding practices.
The goal is to regularly feed the infant approximately 6 g to 7 g of peanut protein, two to three times per week. For example, 2 tsp of peanut butter can be mixed with 2 tsp to 3 tsp of breast milk, water or formula or can be mixed into a pureed food. The mixture should be stirred until dissolved and well blended. Another option is to use a peanut puff product such as Bamba, which can be softened for younger infants.
Healio: How should I introduce other allergens, such as milk, egg, tree nuts and fish?
James: Currently, there is not sufficient information from clinical research studies recommending the early introduction of other food allergens such as cow milk, sesame, wheat, tree nuts, fish and seafood. With this said, there does not appear to be any benefit in delaying the introduction of these foods in developmentally ready infants.
A practical approach is to introduce these foods in age-appropriate amounts and fashion. Allergenic foods can be introduced one at a time to gauge if there is a reaction. The introduction of a new food every 3 days is sometimes recommended to observe if a new food causes an adverse reaction. Once the new food is introduced and tolerated, it should be fed on a regular basis.
Lang: In general, I recommend starting to try small bites of scrambled egg, yogurt or cheese, or tree nuts in single-source form (crushed nut or butters), as well as fish, at home one at a time starting around age 6 months. The most important thing to remember is that once you introduce a potential allergen food, you need to keep it in your baby’s diet regularly.
Healio: Is early introduction of allergens safe? How likely is it that my infant will have a reaction?
James: In general, the early introduction of food allergens is safe if the infant is developmentally ready to ingest solid foods. Infants with atopic dermatitis and/or other food allergies would be at an increased risk for an allergic reaction. Offer allergenic foods for the first time at home, and not in another setting (eg, daycare facility). It is advised that at least one adult be present to give their full attention to the infant and be available for 2 hours afterward in the event allergy symptoms develop.
Lang: Babies with eczema are at higher risk for having food allergies but, unfortunately, we do not have great predictors of which babies might react or how severe reactions might be. Always discuss with your pediatrician or allergist if you are nervous about trying new foods at home.
Healio: Do I still need to introduce allergens early if I am breastfeeding?
James: Yes, early introduction of food allergens is recommended in breastfeeding mothers as a method of preventing food allergies. Appropriate early introduction of food allergens based on current guidelines is the key to food allergy prevention. Breastfeeding is appropriate and recommended throughout this process. Although there are many well-known benefits of breastfeeding, there is a lack of evidence to support the role of exclusive breastfeeding in either preventing or delaying the onset of specific food allergies. Current research does not support restricting a mother’s diet in pregnancy or while breastfeeding to prevent food allergy in infants, nor does research support eating allergenic foods more than what the mother usually eats during pregnancy or breastfeeding to prevent food allergy.
Healio: Do any infants need to see an allergist or have testing before they eat highly allergenic foods?
James: In general, there is no need for all infants to have an allergy consultation and/or allergy testing before an allergenic food is offered and introduced at home. Infants at no or low risk for food allergy should be introduced to solid foods, including allergenic ones, around 6 months at home. Of note, current national guidelines recommended that allergy testing (eg, skin or blood testing) be considered for peanuts before early introduction in infants with a history of severe eczema and/or egg allergy. If positive, these infants may need to undergo a supervised oral food challenge by a specialist to confirm whether the child is truly allergic.
Healio: What does an allergic reaction look like in an infant?
James: Allergy symptoms usually develop within minutes of eating a food but can occur up to 2 hours after ingestion. The most common symptoms of a mild allergic reaction in an infant involve the skin including isolated itching and skin rashes (eg, hives). More severe symptoms include swelling of eyes, lips, tongue, hands and feet, as well as vomiting and diarrhea. Cough and wheezing can be observed in some cases. Typically, anaphylaxis is less frequent and less severe in infants compared with older individuals experiencing allergic reactions to foods.
Lang: Most allergic reactions in infants are mild and consist of skin symptoms such as a red blotchy rash, hives or mild swelling around the lips or eyes. More serious reactions can include other symptoms such as vomiting, itchy or watery eyes, cough, runny nose or nose congestion. In severe cases, trouble breathing or low blood pressure can occur. If you are concerned about a serious allergic reaction, call 911 and seek emergency care right away.
Healio: What should I do if an allergic reaction occurs?
James: First, stop feeding the specific food that seemed to cause your infant’s allergic reaction. Call your health care provider’s office to report the reaction, to review the actual symptoms, and to decide what treatment should be administered. If the reaction is very mild, such as isolated skin rash (eg, hives) and itching, an antihistamine can be given. If the reaction is progressing and becomes more generalized and severe, seek immediate medical attention, and call 911 to help determine the next steps in therapy. If an appropriate epinephrine autoinjector is on hand, it should be administered to an infant who is having an anaphylactic reaction. An emergency room visit may be needed. Stay in touch with your health care provider and schedule a follow-up clinic visit to discuss the allergic reaction and what to do next.
Lang: At home, an antihistamine such as cetirizine can help with mild symptoms of rash or itching, but the only medication that can stop a severe allergy reaction is epinephrine, .
Healio: Should I still introduce allergens early if my baby has eczema?
James: The presence of eczema in your infant does not preclude you from the early introduction of food allergens. In fact, infants with eczema are at an increased risk for developing food allergies over time. Therefore, they are good candidates for this early introduction process.
For infants with severe eczema with or without egg allergy, national guidelines for peanut allergy prevention suggest allergy testing to peanut protein (eg, skin test or blood test). If the testing is negative, peanut protein can be introduced at age 4 to 6 months at home or in a medical clinic. If the allergy testing is positive, a referral to an allergist is recommended for an evaluation. The key here is to not delay the introduction of peanut protein if possible.
Lang: If a baby’s eczema is mild, we recommend still proceeding with normal food introduction, including common allergens. If your baby has more moderate or severe eczema, we also typically recommend introducing allergens, but you should check with your pediatrician and/or allergist first to make sure it is safe.
Healio: If my infant is older than the recommended age to introduce allergens, what should I do?
James: Peanuts can be introduced into their diet at any time if it is done in an appropriate way based on age and developmental level to prevent the risk of choking. Other solid foods can also be introduced in an age-appropriate way. If you have concerns about introducing allergenic solid foods into the diet of your infant or child, a discussion with your health care provider can be helpful.
Healio: Do these recommendations apply to everyone?
Lang: As always, no one recommendation is always right for all families. Make sure to discuss any questions/concerns with your child’s pediatrician and allergist.
Healio: Will these recommendations prevent all infants from developing food allergies?
James: No, these recommendations will not prevent all babies from developing food allergies. But the appropriate early introduction of food allergens in infants, especially those at higher risk for developing food allergies, has been shown to drop the rates of food allergy quite substantially.
For more information:
John M. James, MD, can be reached at jm.james59@outlook.com.
Abigail Lang, MD, MSCI, can be reached at alang@luriechildrens.org.
Scott H. Sicherer, MD, FAAP, can be reached at scott.sicherer@mssm.edu.